Spiritual Psychotherapy for Adolescents with Conduct Disorder: Designing and Piloting a Therapeutic Package.

Objective: Spiritual psychotherapy has been conceptualized in the context of love and belief as principles of existence. Spiritual psychotherapy can provide an opportunity to design programs to treat conduct disorder. The aim of this study was to introduce the Spiritual Psychotherapy Package for Adolescents with Conduct Disorder and execute it as a pilot study. Method: The intervention is a manual-guided program conducted over 14 group sessions, using the perspectives of object relations and attachment approach. It was executed for a group of eight adolescent boys with conduct disorder (mean age: 17.01 years) at Tehran reformatory. The Aggression Questionnaire and the Attachment to God Inventory were completed pre- and post-intervention. Results: There were no significant differences in outcome measures from pre- to post- intervention. Cohen's dav was applied to estimate the measure of the effect size in this study. Cohen's dav measures of avoidance and anxious attachment to God showed acceptable effect sizes. However, Cohen's dav measure of verbal aggression indicated a small effect size. Conclusion: We found evidence indicating acceptability of spiritual psychotherapy among adolescents with conduct disorder in attachment to God.

Spiritual interventions that are independent of secular, evidence-based treatments for children and adolescents do not inherently depend on any particular theoretical orientation, but they have been adapted to treat children and adolescents on the basis of different theoretical perspectives (7). A majority of studies found that antisocial behaviors such as delinquency and criminality were less prevalent among religious individuals (8). For example, Laird et al. (2011) found an association between low religious tendencies and high antisocial and rule-breaking behaviors among adolescents (9). Johnson (2003) reported less return to prison among those who participated in faith-based prison programs than among those in a control group (10). In this study, we introduced a Spiritual Psychotherapy Package for Adolescents with Conduct Disorder as a manual-guided program to be executed in 14 group sessions, which employs the perspectives of object relations and attachment theories. Attachment and object relations theories provide a framework to explain interpersonal relationships (11) and delineate an integrative model to understand the problems of conduct disorder. The early relationship with primary caregiver forms expectations for the self and others, and influences the interpersonal interactions over the lifetime (12). An unavailable and rejecting caregiver can develop an avoidant-insecure attachment pattern in the child, which may result in conduct disorder (13). Several studies have reported avoidant and insecure attachment patterns among children and adolescents with conduct disorder (14)(15)(16)(17)(18)(19). Nevertheless, there is a compensatory mechanism for insecure attachment; attachment to God can compensate for insecure human attachments (20). Overall, spiritual psychotherapy can play an important role in improving the attachment patterns of adolescents with conduct disorder . The aim of this study was to design and introduce the Spiritual Psychotherapy Package for Adolescents with Conduct Disorder and execute it as a pilot study. Based on previous research 12, 13,20) we anticipated that, compared to the baseline, at study completion attachment to God would have increased and aggressive behavior decreased.

Materials and Methods
We designed the Spiritual Psychotherapy Package for Adolescents with Conduct Disorder using the perspectives of object relations and attachment theories, as fourteen 90-minute sessions for groups of 6 to 8 adolescents with conduct disorder, aged 14 to 18 years, with or without substance use or attention deficit hyperactivity disorders; this package was introduced to the participants who were resident in reformatories . As demonstrated in Table 1, the 14 group therapy sessions of the Spiritual Psychotherapy Package for Adolescents with Conduct Disorder draw on principles of existence including belief in the sacred, belief in unity, and belief in transformation, love of others, love of work, and love of belonging (6); it also draws on spiritual interventions including acceptance, spiritual awareness, prayer, sacred texts, God images and forgiveness (7). These 14 sessions targeted impaired object relations in adolescents with conduct disorder including insecurity and fear, pessimism and mistrust, inability and abjection, and non-maintenance of boundaries and limits (21) and seeks to reform them. In the sessions, the stories, group discussions, allegories, verses of Quran, writing, poetry, meditation, painting, spiritual guided imagery, and prayer were used as practices (7,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31). The designer and deliverer of the package was a PhD by research candidate in clinical psychology, who had successfully completed psychoanalytic group therapy and spiritual psychotherapy courses at the Tehran University of Medical Sciences. The therapist who delivers the package should at least have a master's degree in psychology, be interested and trained in spiritual psychotherapy, have adequate motivation to work with adolescents with conduct disorder, and should also complete 10 to 14 workshop sessions to learn to implement the package . The Spiritual Psychotherapy Package for Adolescents with Conduct Disorder was designed based on object relations of adolescents with conduct disorder (21) in focused sessions with experts. To assess the validity of the package, eight experts rated each session from 0 to 7 and provided their suggestions to improvement via a validity evaluation form . To test the feasibility of the package, it was delivered to a group of eight adolescent boys with conduct disorder aged 14 to 18 years, from February through March 2015 at Tehran reformatory. Inclusion criteria were: diagnosis of conduct disorder (DSM 5: 313.81); age 14 to 18 years; males, uninterrupted stay at a reformatory; written informed consent. Exclusion criteria were: acute suicidality; acute psychosis. The Aggression Questionnaire (32) and The Attachment to God Inventory (33) were completed before and after administration of the package. The study was approved by the Tehran University of Medical Sciences (Tehran, Iran) and conducted in accordance with the rules laid down in the Declaration of Helsinki.

Measures Aggression
The Aggression Questionnaire contains of 29 questions with four subscales covering physical aggression, verbal aggression, hostility, and anger; scores on the four subscales are summed to provide a total aggression score. These subscales have internal consistency over time (32). Mohammadi (2006) reported Cronbach's alpha, retest, and split-half of 0.89, 0.78 and 0.73, respectively (34). In another study a reliability coefficient of 0.78 was reported for the Persian version of the Aggression Questionnaire (35).

Attachment to God
The Attachment to God Inventory is a 24-item scale that measures two subscales of avoidance and anxious attachment to God. Beck and McDonald (2004) reported factor eigenvalue of 6.51 and 3.88 for avoidance and anxious subscales, respectively (33). Olyaei et al. (2011) reported Cronbach's alpha, and retest coefficients of 0.68, and 0.58 for the Persian version of the Attachment to God Inventory (36(.

Statistical Analysis
Distributional data characteristics revealed normal distribution, and parametric tests were applied. Paired samples t-test was used to examine pre-to postintervention differences using SPSS 16.0 (SPSS, Chicago IL, USA). Since Cohen's dav is used for within-subjects designs, we applied it to estimate effect sizes in this study.

Results
Six out of the eight enrolled participants completed the intervention and all the study assessments; two participants were released from the reformatory and could not complete the program. The mean age of the participants was 17.1±0.75 years in this study. The mean years of education, and maternal and paternal education were 8.8, 8.4 and 6.8 years, respectively. Of the participants, four had a history of crime, four of their parents were divorced, five of them and their family members had substance use disorder, and three family members with criminal and psychiatric disorder histories. As Table 2 indicates there were no significant differences in outcome measures between pre-and post-treatment. There were decreases in scores on the avoidance and anxious attachment subscales of the Attachment to God Inventory from pre-to posttreatment. Cohen's dav measures for these two subscales showed acceptable effect sizes. However, an increase in the mean measures of the verbal aggression indicated an increase in the verbal aggression in the post-treatment as compared to the pre-treatment. Cohen's dav measure of verbal aggression indicated small effect size ( Table 2). Figures 1 and 2 present the changes in anxiety and avoidance in graphical form. The graphs show that anxiety scores of three participants decreased, remained stable in the case of two participants, and in the case of one participant worsened. Avoidance score decreased for five participants, while for one participant it increased.

Discussion
This is the first study to design and introduce the Spiritual Psychotherapy Package for Adolescents with Conduct Disorder and conduct it as a pilot study to investigate the effects of the treatment on participants' attachment to God. Because of the small sample of the pilot study, no significant differences in outcome measures were found between pre-post-treatment. However, acceptable effect sizes were observed with respect to avoidance and anxious attachment to God, indicating that these could be reduced by this intervention. Although verbal aggression had increased following treatment, this may be due to the intimate environment of the sessions, which enabled expression of verbal criticism rather than physical aggression. Arguments have been made for the benefits of various psychological interventions in reducing the symptoms of conduct disorder, including family and parenting interventions, multi-systemic therapy, parent management training, functional family therapy, various behavioral management strategies, multidimensional treatment foster care, and cognitivebehavior skills building programs (37)(38)(39). Nonetheless, they have had limited effectiveness in the treatment of conduct disorder, particularly among adolescents where the problems have been severe and associated with seriously disturbed families (5). A majority of studies have shown religiosity and spirituality to have significant effects on delinquent and antisocial behaviors (8,9,(40)(41)(42)(43)(44). No significant effect was observed in the intervention, however, if the intervention introduced in this study were to be tested with conduct disordered adolescents in clinical trial designs this may confirm the findings of the previous research that has used spiritual interventions with delinquent groups. For example, Johnson (2003) reported less return to prison among those prisoners who participated in a faith-based prison program as compared to a control group. Hausmann and Spooner (2009) provided pastoral counseling interventions for 16 adolescent male delinquents and found such counseling to be a contributing factor in successful treatment and low recidivism (45). In addition, several studies have reported avoidant and insecure attachment patterns among children and adolescents with conduct disorder (14)(15)(16)(17)(18)(19), and have also found that attachment to God can compensate for insecure human attachments (20). Having designed the Spiritual Psychotherapy Package for Adolescents with Conduct Disorder the pattern of results suggested that the intervention had a favorable influence. Therefore, we suggest that this package be implemented in clinical trials with control group.

Conclusion
We introduced the Spiritual Psychotherapy Package for Adolescents with Conduct Disorder and executed it as a pilot study.
Because of the small sample of the pilot study, no significant differences in outcome measures were found between pre-post-treatment. However, we found evidence indicating acceptability of spiritual psychotherapy among adolescents with conduct disorder in attachment to God.

Limitation
This study had the following limitations: 1) participants in this study were from one reformatory in Iran and due to the small sample size, the results of this study are not representative of all Iranian adolescents with conduct disorder; 2) lack of control group; 3) lack of follow-up; 4) No experts' ratings.